Primary health care organization in the Covid-19 pandemic: scoping review

ABSTRACT OBJECTIVE Mapping available scientific evidence on the organization of primary health care services and professionals during the Covid-19 pandemic. METHODS This is a scoping review that followed the Joanna Briggs Institute method. Articles published in Portuguese, Spanish, and English from January 2020 to January 2021 in the CINAHL, Lilacs, Medline, PubMed, and Web of Science databases were included. RESULTS We selected 24 articles that presented the reorganization of primary health care services and professionals to care suspected or confirmed Covid-19 cases. Coordination measures to tackle this disease in primary health care help to control its infection, especially by the active search for respiratory symptoms, the detection of new cases, and the monitoring of confirmed cases. CONCLUSION This study presents an overview of how primary health care services and professionals organized themselves to tackle the Covid-19 pandemic, addressing adjustments in infrastructure and care flows, such as establishing specific Covid-19 care units, separating infected and non-infected patients, using telemedicine as an alternative modality of care, and monitoring cases by applications and phone.


INTRODUCTION
In order to tackle the pandemic of the new coronavirus, health systems worldwide had to adjusted themselves to provide different responses against its infection, prevent its spread, and reduce the sequelae caused by Covid-19 in the population. Due to the high transmissibility rate of this disease, it rapidly spread worldwide, resulting, from the beginning of the pandemic to the first quarter of 2022, in more than 500 million confirmed cases and more than six million deaths worldwide 1 . During the same period, Brazil had more than 30 million confirmed cases and the number of deaths has already exceeded 660,000 2 .
The pandemic posed challenges for health systems, showing their weaknesses by exposing chronic funding and management problems 3 . Preparing these systems to tackle emerging infectious diseases, by evidence-based planning and strategies and coordination between all segments of a system and the government, is important.
In Brazil, primary health care (PHC) stands out since it is generally the main gateway for health services in the Brazilian Unified Health System (SUS). PHC is organized in order to solve most health problems of individuals and their families and played a fundamental role in the fight against the pandemic, as most infected people developed a mild form of the disease, which allowed their follow-up to be performed at this level of care [4][5][6] .
Considering actions to be developed to tackle Covid-19, especially in PHC, the knowledge of the territory, the access, the link between patients and health teams, the integrality of care, the monitoring of vulnerable families and suspected and mild cases of the disease allow the development of essential strategies to contain the pandemic and prevent the worsening of Covid-19 7 .
In Brazil, PHC remains a central point in the organization of the SUS, thus, strengthening and organizing it is necessary, in order to make it a pillar to tackle Covid-19, due to its capacity to link, manage, and monitor cases during the pandemic, and resume its routines after the pandemic, based on the context of the Country as a whole 7,8 .
Thus, PHC is essential to tackle Covid-19 worldwide, developing educational, preventive, health-promoting, care, and administrative actions. All health professionals and managers are responsible for organizing PHC in order to provide effective services and it must be done not only in health units, but throughout Brazil and at home.
Studies on the evolution and treatment of Covid-19, as well as its vaccines, have been published, however, mapping scientific evidence on studies on the organization of PHC health services and professionals and its effect on tackling the pandemic is necessary.
Thus, this study shows gaps on the topic and reflects on the organization of actions to mitigate Covid-19 at this level of care, allowing the planning of strategies to tackle this disease in order to provide a resolutive and quality care of the population. Therefore, this study aimed to map available scientific evidence on the organization of PHC services and professionals during the Covid-19 pandemic.

METHODS
This is a scoping review that followed the Joanna Briggs Institute (JBI) method: (1) identification of the research question, (2) identification of relevant articles, (3) selection of articles, (4) data extraction, (5) separation, summarization, and reporting of results, and (6) dissemination of results 9 . The articles studied presented a global picture of how PHC professionals and services organized themselves to tackle the Covid-19 pandemic, especially by the use of technologies and telemedicine. In total, 17 (71%) articles addressed this alternative modality of care and the monitoring of cases by applications, phone, and online platforms (Box 2).
Moreover, 13 (54%) articles addressed adjustments in infrastructure and care flows, such as the adoption of specific Covid-19 care units, the separation of infected and non-infected patients in health units, and changes in the work process and infrastructure (Box 2).
Three (12.5%) articles studied the importance of health education on Covid-19 for the community and health teams and three (12.5%) analyzed the care of chronic patients during the pandemic. Two (8.5%) articles assessed the organization of PHC services and professionals based on previous experiences, such as the H1N1 pandemic (Box 2). Box 2. Selected articles, according to place and year of publication, objective, type of study, and main results.

Author, year, and place Objective Type of study Main results
Krist AH et al. 18 , 2020, United States Presenting actions to be adopted by PHC during the pandemic, according to the protocol of the Centers for Disease Control and Prevention (CDC).

Descriptive study
The plan to tackle the Covid-19 pandemic in PHC was organized into six phases: 1) surveillance, notification, and monitoring of cases; 2) physical distancing, increasing virtual appointments, and postponing non-urgent appointments; 3) implementation of actions to flatten the epidemiological curve; 4) referral of only severe cases to hospitals; 5) care actions for convalescent patients; 6) addressing the consequences of the pandemic.
Morreel S et al. 19 , 2020, Belgium Assessing the organization and characteristics of PHC appointments performed outside office hours and comparing them with those in the same period in 2019.

Observational study
By telephone screening, patients were classified as suspected or regular. All suspected Covid-19 cases were treated virtually, and, if necessary, referred to exclusive care units for Covid-19 suspected patients (Corona Units), or in home visits, or referred to emergency departments. In comparison with 2019, the workload increased due to phone calls, however, the number of face-to-face appointments decreased by 45%.
Fernandes LMM et al. 20 , 2020, Brazil Analyzing the adaptation of a PHC center in Recife, which improved its telehealth and remote monitoring.

Case report
Reorganization of the internal flow of the unit, by separating symptomatic from asymptomatic patients; discontinuation of collective activities; maintenance of the follow-up of patients with chronic diseases; telemedicine and remote monitoring; and active surveillance actions promoted by the health team in the territory.
Sigurdsson EL et al. 21 , 2020, Iceland Analyzing how PHC in Iceland changed its strategy to tackle the Covid-19 pandemic.

Observational descriptive study
Early detection of suspected cases; effective screening; separation of symptomatic and asymptomatic patients; maintenance of activities aimed at maternity and childcare; change from face-to-face care to telemedicine; alternative office hours. Change in the 10 main diagnoses-immunization, depression, hypothyroidism, and low back pain were no longer among the 10 main diagnoses. These changes showed a very solid PHC, with great flexibility in its organization.

Dias EG 22 , 2020, Brazil
Discussing the management of care and health education in PHC to tackle the Covid-19 pandemic.
Experience report Immediate identification of respiratory symptoms; space reserved to wait for an appointment; discontinuation of some care activities; telemedicine and telemonitoring; home visit or face-to-face care, if necessary; health education by radio, sound cars, flyers, posters, social networks, and phone.
Vieira DS et al. 23 , 2020, Brazil Developing an experience of organizational planning in nursing along with the family health team in a rural area of Igreja Nova, AL, during the Covid-19 pandemic.
Experience report This study followed three strategies: • Community guidance on the problem of health prevention and promotion actions. • Permanent health education for the health team, in order to qualify professionals. • Organization of the provision of health services, establishment of an exclusive room to treat respiratory symptoms, and organization of the care of patients of programs in the unit.

Cross-sectional study
The rate of phone and video appointments more than doubled during the study period (106.0% and 102.8%, respectively). Face-to-face appointments decreased by 64.6% and home visits by 62.6%. This process coincided with national policy changes. The relative increase in the number of appointments was associated with people taking ≥ 10 medicines in comparison with those who did not take any.
Al Ghafri T et al. 39

Experience report
Technological support and remote approach are essential to assess Covid-19 primary care. The use of telemedicine and the aid of technology allowed an efficient monitoring of patients at home, reducing inadequate hospitalizations, as patients were referred to a hospital only when necessary.

DISCUSSION
The 24 articles selected in this study addressed the reorganization of PHC services and professionals and the surveillance in the monitoring of Covid-19 cases for the care of suspected or confirmed cases.
In March 2020, after the declaration of community transmission of this disease throughout Brazil, the Secretariat of Health Surveillance of the Ministry of Health adapted the Sistema de Vigilância de Síndromes Respiratórias Agudas (SRAG -Acute Respiratory Syndromes Surveillance System), aiming to guide the Sistema Nacional de Vigilância em Saúde (SNVS -National Health Surveillance System) during the simultaneous circulation of SARS-CoV-2, influenza, and other respiratory viruses, within More than 80% of physicians notified patients. The waiting time for phone interviews, epidemiological investigation, and availability of isolation progressively decreased from an average of six days to 0.4 days in the 12th and 16th weeks of 2020, respectively. The cumulative weekly notification rate of new cases ranged from 3.54 to 6.84 cases per 1,000 inhabitants in the 12th and 16th weeks, respectively. From the epidemiological investigation of 1,471 probable cases, 2,514 close contacts were identified and, in turn, quarantined at home.
Duarte RB et al. 43  Experience report The role of community health agents is to be a mediator between health teams and the population, developing guidance actions on the functioning of preventive services and self-care related to Covid-19 in the territories where they work. Nurses also play an important role in the training of community health agents regarding the reorganization of the work process during the pandemic and the appropriate use of personal protective equipment.

Cross-sectional study
This study assessed 51 PHC services and identified problems in infrastructure and infection control.
Care for chronic non-communicable diseases, immunization, prenatal care, and maternal and child health were the most affected areas.
On the other hand, in screening sites for flu symptoms, the number of appointments increased.
Danhieux K et al. 48 , 2020, Belgium Evaluating how PHC services aimed at chronic conditions was affected during the pandemic in Belgium.

Qualitative research
The health care organization changed, starting to focus on suspected Covid-19 cases and the use of telemedicine, and decreasing the provision of care for chronic conditions. Most professionals interviewed did not perform risk stratification and active search for patients at higher risk-telemedicine was used to evaluate and prescribe medicines and not to monitor chronic conditions. The provision of care for chronic conditions was sharply discontinued.
the scope of the Emergência em Saúde Pública de Importância Nacional (ESPIN -Public Health Emergency of National Importance) 12 .
This context shows the importance of the role of health surveillance in the notification, investigation, and monitoring of severe and confirmed Covid-19 cases 13 . Health surveillance actions are essential for the PHC organization in this new scenario, by the development of actions that enable the early identification of suspected cases, immediate notification, active search for contacts, reinforcement of home isolation, health education, and support to vulnerable groups in Brazil 14 .
The Covid-19 pandemic increased the demand for care in the SUS, which made the Brazilian Ministry of Health reinforce the need for organization of the care network and care flows both for people with flu-like diseases, including Covid-19, and who needed follow-up for other health conditions 12 .
Thus, during the Covid-19 pandemic in Brazil, the main strategy of PHC to tackle this disease was reorganizing the work process of health professionals, especially by health education activities, as it builds knowledge to provide self-care 15 . All countries had to reorganize and strengthen the responsiveness of PHC services, according to their public policies, and ensure care for other health demands of the population 16  , recommending the reorganization of PHC services and the work process to tackle the pandemic. This protocol established measures to prevent infection in health services, models for stratification of the severity of suspected cases, actions for therapeutic follow-up and home isolation of mild cases, measures for stabilization and referral to services of greater complexity, and actions to promote community prevention measures 17 .
The reorganization of the physical structure of PHC services was one of the main strategies to reduce risks of infection in health units, speed up services-avoiding contact between patients with and without suspected Covid-19-and protect professionals, maximizing the efficiency of the services provided.
Studies performed in Brazil, Belgium, Iceland, and the USA adapted health units to maintain physical distancing, adopted the immediate identification of symptomatic cases at reception, limited the number of companions, separated rooms for symptomatic and asymptomatic patients, and reorganized the care of priority groups assisted by the service [18][19][20][21][22][23] .
In Diadema, SP, the health management decentralized the care to respiratory symptomatic patients in all PHC units, considering the capillarity of PHC with family health teams. Thus, all services at this level of care adopted this demand 24 .
In Florianópolis, SC, Sobral, CE, and Belo Horizonte, MG, health units with adequate physical space also organized care flows separately: they treated suspected and confirmed Covid-19 patients in different places from other patients [25][26][27] .
On the other hand, one or more specific health units centralized the care of respiratory symptomatic patients. The organization of these services presented similarities, such as the respect for the instructions to patients on personal hygiene care and use of masks and the redesign of physical spaces to respect physical distancing [28][29][30] .
England created specific care units for Covid-19 patients and those who were unable to go to a health unit or did not need hospital care were monitored at home 30 .
In Rochester, Minnesota, USA, this same strategy was adopted to avoid contact between confirmed or suspected Covid-19 patients and other patients. Of the five health units in this city, one was adjusted to exclusively care for Covid-19 patients or people with symptoms of respiratory problems. Initially, they adopted phone screening to evaluate if patients needed hospital care or could be cared at the Covid-19 unit 28 .
In Australia, PHC started using telemedicine and call centers to screen people with respiratory symptoms, as well as developing a national network of complementary respiratory units. Moreover, health professionals participated in online trainings and health protection measures for Aboriginal communities and the population of the Torres Strait islands were disclosed 42 .
In the United Kingdom, the number of remote appointments doubled while face-to-face appointments and home visits decreased. In total, three-quarters of PHC patients were remotely cared 30,38 . In Iceland, the number of phone or online appointments increased by 127% and the number of remote medicine prescriptions and appointments also increased 18 . France, Italy, and Belgium also presented this increasing trend, since most general physicians adapted their activities to the remote modality 19,29,40 .
In Italy, the monitoring and follow-up of Covid-19 patients was performed remotely, by social networking applications, and twice a day, including the monitoring of the vital signs of patients, which were measured by smartphones. In cases of difficulty to monitor vital signs by technological devices, patients could borrow a pulse oximeter to check their saturation and heart rate at home 40 .
Although telemedicine allows the continuity of care remotely, this change can hinder the practice of general physicians due to the loss of non-verbal communication, the limited capacity of some patients to articulate their needs, and the association between intercultural communication and language problems, which are barriers in care 34 .
A study performed with the older adults cared by PHC in the United Kingdom showed that health professionals must be aware that remote appointments, especially in the case of video calls, may represent an additional barrier in the care of vulnerable groups, who have limited access to the Internet, smartphones, and other technologies 38 .
The Covid-19 pandemic promoted innovation in the care provided by PHC, since health units had to adapt themselves to physical distancing measures. However, PHC must evaluate the efficiency of remote care and identify the possible difficulties of a group in the use of the necessary technologies.
In the scope of PHC, education actions became stronger in the care provided by health professionals to limit the spread of Covid-19 22,23,32,34,43,44 . We highlight the difficulty of dealing with community rumors and misleading information, which directly affected the care process during the pandemic. Thus, integrating technology support and disseminating reliable guidelines is important 32 .
Adherence to prevention measures against Covid-19 is related to health education actions carried out by health professionals. In this sense, digital technologies are important to disseminate information about the prevention of this disease by social networks. They also reinforce the fundamental role of community health agents in health education, especially in the fight against fake news and the mediation between PHC and the community 22,43 .
In a Brazilian municipality, family health teams, along with community agents, carried out health education activities for the population. These actions aimed to guide the population on preventive measures against Covid-19 and disseminate epidemiological data by radio, sound cars, flyers, social networks, and phone. However, the number of suspected Covid-19 cases did not decrease, showing the importance of people's adherence to the prevention measures 19 . For health education actions to achieve their objectives, developing different strategies to overcome social and cultural barriers that influence the choices of individuals is necessary 22,45 .
During the Covid-19 pandemic, the follow-up of patients with chronic non-communicable diseases (NCDs) was postponed and its number decreased worldwide, since the care of part of this cases was not urgent 21,22,29,32,34,[46][47][48] . In Muscat, Oman, all health units suspended face-to-face care of patients with NCDs at the beginning of the pandemic 32 . In Spain and Belgium, although this suspension did not occur, the number of follow-ups of patients with diabetes mellitus and systemic arterial hypertension significantly decreased 46,48 .
The administration of vaccines in children reduced in Spain 46 and outpatient services related to maternal and child health were discontinued in India 47 . France maintained outpatient care for other health problems while the Covid-19 care was directed and concentrated in specific centers 16 .
The postponement of the care of patients with NCDs, childcare, and the reduced vaccination coverage may have consequences that will extend after the Covid-19 pandemic, causing an overload in health systems 21,29,34,46 . On the other hand, the reduced attendance of patients with NCDs to health units is probably related to the health authorities' recommendations for people to stay at home and seek these services only if in case of Covid-19 symptoms 29 .
Although health professionals working in PHC quickly organized themselves in response to the beginning of the pandemic, the targeting of Covid-19 care can cause health complications for a part of the population, whose care was postponed or suspended, and burden the health system.
Thus, the guarantee of comprehensive care during the pandemic became a major challenge for PHC, due to the valorization of care in hospital services and the detriment of other needs of the population 5,22,43,45 . Therefore, the pandemic reinforces the need to strengthen the role of PHC in the organization of health services in the SUS, as a way to optimize expenses and reduce hospitalizations, both for Covid-19 and other causes related to this level of care.
In Brazil, the Ministry of Health published guides and ordinances to guide PHC services and professionals. Moreover, state health departments, along with the Conselho Nacional de Secretários de Saúde (CONASS -National Council of Health Secretaries), supported municipal managers when discussing about restructuring services; however, despite of regulations, each municipality adapted itself according to its local reality and epidemiological, political, and financial issues.
PHC works as an organizer in the health network, which increases its importance in the fight against the Covid-19 pandemic, as it manages the early identification of suspected cases, the monitoring of mild cases, and the identification and referral of severe cases, besides contributing to reduce the burden of specialized and hospital services, which, consequently, reduces public spending.
This study presents an overview of how PHC services and professionals organized themselves to tackle the Covid-19 pandemic, addressing adjustments in infrastructure and care flows, such as establishing specific Covid-19 care units, separating infected and non-infected patients, using telemedicine as an alternative modality of care, and monitoring cases by applications and phone. However, gaps still exist in the literature, such as the evaluation of the effect of these actions and their effectiveness in mitigating the Covid-19 transmission, the analysis of the consequences for patients whose care